Saeed Akram, Tussadiq Khurshid.
Nonconvulsive Status Epilepticus after a Generalized Seizure.
Pak Armed Forces Med J Jan ;51(1):52-4.
A 15 years old girl was brought to POF hospital at 0945 hours with the history of severe frontal headache followed by jerky movements of body and then loss of consciousness. There was no past history of fits.
On examination she was in deep coma not responding to noxious stimuli. The respiration was stridrous with respiratory rate of eight breaths per minute. Excessive salivation as frothy secretion was coming from her mouth. Eyes were divergent. Pupils were constricted to almost pin point. Fundus oculi could not be examined due to constriction of pupils. Neck was supple. There were no spontaneous movements of limbs. They were flaccid, tendon reflexes were absent and Babinskis were equivocal. Her blood pressure was 130/90 mmHg and pulse 58/min. She was considered to be in post ictal phase after a generalized tonic clonic seizure. A possibility of organophosphorous poisoning or a possible intra cranial catastrophe was considered. Keeping in mind depressed respiration and constricted pupil opium poisoning was also considered. The parents strictly denied any exposure to insecticide or any drug intake except two tablets of mefenemic acid that she took when she suffered from headache. She was given inj atropine 1 /2 ampoule I/v stat. Her airway was cleared of secretions by suction and she was kept in semi prone coma position and shifted to ITC for possible assisted ventilation. Injection Nalaxon 2mg I/V was given and then repeated when no change in the level of consciousness was observed.
At 1045 hrs she was reassessed, her level of conscious had not improved Breathing was still laboured and stridrous, pupils constricted, pulse 130/min blood pressure 150/100 mmHg. Endotracheal tube was passed. There was no gag reflex. She was put on respirator with SIMV mode at rate of 12 breaths per minute. She was put on generalized convulsive seizures at 30 minutes interval which were controlled by injection valium. After the second fits she was paralyzed by inj pavulon 4 mg and volume control mode of ventilation started. Another fits occurred at 1245 hrs, which was controlled by inj pentothal. Inj valium infusion 2 mg/hour was also started and was discontinued later on.
At 1830 hrs, after eight hours of artificial respiration, she was weaned off respirator with endotracheal tube still in position. She started responding to noxious stimuli initially by moving right arm only. At that time no spontaneous movements of left arm or legs were observed. Pupils were still constricted and fundus oculi were not still visualized. Endtoracheal tube was removed after half an hour. Gradually she gained consciousness, initially started responding to verbal command and then became fully conscious at 2200 hrs. She remembered the headache and taking of tablets of mefenemic acid. Her physical examination including fundus oculi did not reveal any abnormality. Her investigations including blood complete picture and urine analysis serum urea, blood sugar and ECG were all within normal limits. She was kept in the hospital for five days and discharged symptom free without any neurological deficit on tablet epival 250 mg twice daily.
If a patient fails to regain consciousness after a seizure the possibility of non-convulsive seizures should always be considered. An EEG is a very useful test to rule out the possibility of status epilepticus. It is very essential to put a protocol in place in initiating antiepileptic medications for status epilepticus. Although I have only looked at the abstract, I am quite surprized not to see any mention of I/V phenytoin in the treatment of S.E.
S. Nizam Ahmed, MD, FRCPC
University of Alberta
Posted by: nizamahmed on Dec 2003
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